BIOSENSE WEBSTER INC TRUDI¿ NAVIGATION SYSTEM; EAR, NOSE, AND THROAT STEREOTAXIC INSTRUMENT
|
Back to Search Results |
|
Catalog Number FG200000 |
Device Problem
Image Orientation Incorrect (1305)
|
Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
|
Event Date 08/01/2023 |
Event Type
malfunction
|
Event Description
|
It was reported that a patient underwent a functional endoscopic sinus surgery (fess) with a trudi¿ navigation system and a location inaccuracy occurred.It was reported that during a primary surgery, the trudi curette was displayed on the trudi system inaccurately and in the brain.The caller stated that the trudi curette was displayed on the trudi system about 4mm off in comparison to the suction device that was placed in the same location.Additional information received indicated a location inaccuracy was determined only in this one area of anatomy in the middle of the workflow of the case.It was determined from the curette reading significantly differently from suction in same exact anatomy.Additionally, the curette was depicted in brain 4mm across the skull base bone -rather than in nasal cavity where surgeon was operating.Accuracy had been previously validated by both using the registration probe and through instrumentation.The registration was performed by a fellow and was good.A first registration was performed and he accidentally hit the ¿back¿ button to accept before he was finished.Therefore, we re-registered before starting the case and noted excellent accuracy.Accuracy was confirmed on four (4) areas of the face and then intranasally on known, fixed landmarks such as back of maxillary, face of sphenoid.Many ct scans at 0.75mm scan thickness and nearly whole-head computed tomography(ct).Field of view was reported to be great at in angled scope.There were no noticeable defects on the ca scanned images.The trudi¿ navigation system did not indicate any metal interference.The or table was in question since this is the closest point of patient anatomy to the table since they tilt the patient head back.However, that does not explain suction being ¿on¿ and curette ¿off¿.It was reported non-acclarent devices were used, and it was considered the acclarent devices did not function as expected.There was no patient consequence, and no medical intervention was required.This event was originally considered non-reportable, however, a product investigation identified a reportable product malfunction on 1-sep-2023.
|
|
Manufacturer Narrative
|
Device investigation details: an investigation was initiated by the manufacturer to investigate the issue.A software defect was discovered which affects the location accuracy of the curette tool on the trudi system display.The issue is being addressed as part of an internal corrective action.The history of customer complaints reported during the last year associated with trudi system #100121 was reviewed.3 similar complaints were found.The manufacturing record evaluation was performed on trudi system #100121, and no internal actions related to the reported complaint condition were identified.9.Fda correction/ removal reporting no: 3005172759-09182023-001-c.If additional information is received regarding this event, a supplemental 3500a report will be submitted to the fda.Manufacturer's ref.# (b)(4).
|
|
Manufacturer Narrative
|
The manufactured date has been provided.Therefore, field h4.Device manufacture date has been populated.If additional information is received regarding this event, a supplemental 3500a report will be submitted to the fda.Manufacturer's ref.# (b)(4).On 1-nov-2023, the product investigation was reopen to correct the following information: field h6.Investigation conclusions code corrected from "cause traced to component failure (d02) to cause traced to software coding (d18).Also, it was previously reported the history of customer complaints identified 3 similar complaints, however, it was updated to 5 similar complaints.
|
|
Search Alerts/Recalls
|
|
|